Marzanski et al Attitudes to the Hippocratic Oath

These values can make us aware of our history and iden- DYER, A. R. (1999) Psychiatry as a pp. 814-815. Manchester: profession. In Psychiatric Ethics (eds Manchester University Press. tity and provide guidance in a time of change. Articulated S. Bloch, P. Chodoff & S. Green), LOEFLER, I. (2002) Why the Hippocratic pp.74-77. Oxford: Oxford University in a contemporary form, Hippocratic values such as ideals are dead. BMJ, 324,1463. original avoiding harm, acting in the best interest of the patient, Press. papers RODDY, E. & JONES, E. (2002) FULFORD, K. R. (1993) Bioethical blind compassion, integrity, honesty and respect for human life Hippocratic ideals are alive and well in spots: four flaws in the field of view of maintain their relevance and prove that goodness in the 21st century. BMJ, 325,496. traditional bioethics. Health Care medical practice does remain continuous across the ages. Analysis, 1,155-162. ZILBOORG, G. & HENRY, G. (1941) A History of Medical Psychology. London: JASPERS, K. (1963) General Allen & Unwin. Declaration of interest Psychopathology (3rd edn), None.

*Marek Marzanski Psychiatrist, CoventryTeaching Primary Care References Trust,The Caludon Centre, Clifford Bridge Road, Coventry CV2 2TE, email: [email protected], Tim Coupe Clinical Audit/Effective- BRITISHMEDICAL ASSOCIATION (2004) Handbook of Ethics and Law. London: ness Officer, Padmapriya Musunuri , CoventryTeaching Medical EthicsToday.The BMA’s British Medical Association. Primary CareTrust,The Caludon Centre, Coventry

Psychiatric Bulletin (2006), 30,329^333 JULES MASON, TINA IRANI, GARYFALLIA FOUNTOULAKI, SYLVIA WARWICK, JANE DA ROZA DAVIS AND PETER SUDBURY Psychiatry at night: experience of the senior house officer

AIMS AND METHOD RESULTS CLINICAL IMPLICATIONS We gathered detailed prospective Admissions and assessments make up This survey helped to plan service data for first on-call activity of senior a quarter of calls but three-quarters delivery and to monitor the training house officers (SHOs) in order to help of the work. An overnight crisis of SHOs during on call. Screening of plan changes in service provision so service reduced the number of calls by a senior nurse, alternatives to that SHOs in psychiatry complied with assessments made by SHOs out of seclusion and nurse-led prescribing the WorkingTime Directive and to hours by 68%. Screening of calls by a for rapid tranquillisation would have determine whether service changes senior nurse reduced the number of the largest impact on the work affected training experience while calls about in-patients by 60% on generated by in-patients.The over- on call.The incumbent SHOs designed weekday nights. Between 73% and night crisis service reduced the a simple form to monitor on-call 100% of calls about in-patients after number of assessments, but might activity inWest Berkshire. midnight were for assessment of have an adverse impact on training. patients in seclusion and rapid tranquillisation.

Monitoring of hours spent on call by senior house officers related to training: admissions, assessments, risk assess- (SHOs) is compulsory to comply with the Working Time ments, level of senior support, developing management Directive (WTD Expert Group, 2004), but this does not plans and team-working. Herzberg & Paice (2002) yield detailed information of what junior doctors are described a perceived improvement in psychiatry training called to do during on-call hours (Department of Health, after interviewing SHOs from London training schemes. 2005). The workload of trainees on call has been studied In Learning Objectives for SHOs (Royal College of in acute trusts (Baldwin et al, 1997; Paice et al,1997; Psychiatrists, 2002) there is no reference to the learning Hurley & Patterson-Brown, 1999; Brown et al,2002; objectives for the on-call period apart from the general Department of Health, 2005), but the nature of the work expectation that by the end of basic training psychiatrists is very different in medicine, paediatrics and should be able to assess patients in a variety of settings. compared with psychiatry (Callaghan et al,2005).The The Basic Specialist Training Handbook (Royal College of major differences are the greater time necessary for Psychiatrists, 2003) states that each trainee should do 55 assessment and admission, and the less frequent use of nights on call during their basic training, but not what emergency investigations. should be achieved during these nights on call. Callaghan et al (2005) showed that SHOs in We gathered detailed prospective data about first psychiatry appreciated their time on call as a learning on-call activity to help to resolve such issues as resident experience, with nearly two-thirds having confidence in v. non-resident SHOs, tasks that could wait or be taken their decision-making. In that study SHOs made retro- over by other professionals (Modernising Agency, 2006), spective estimates of the on-call work that was directly the impact of an overnight crisis service, the screening of

329 Mason et al Psychiatry at night

SHO called about call att start stop ward SHO called about call att start stop ward psychiatric problem physical problem Miscellaneous advice Miscellaneous advice original Self-discharge Laxative papers Self-harm Paracetamol Observation levels Other pain killer Increasing agitation Antibiotics Refusing medication URTI, SOB, cough Seclusion Chest pain Assessment under Headache, toothache, section 5(2) of Mental earache Health Act 1983 TTO Blood pressure raised ICU transfer Swollen ankles Transfer A&E ^ Raised temperature overdose/suture Rapid tranquillisation Skin problem Acuphase Fall Chlorpromazine Rectal problem Zopiclone/zolpidem Collapse Lorazepam Abdominal pain Diazepam UTI Phlebotomy Resuscitation Pharmacy Transfer for treatment Other medication Transfer for investigation ECT prescribing Notes missing Patient absent without leave Drug card lost Rewrite drug card Clozapine Side-effects Admission

SHO, senior house officer; TTO, to take out; ICU, intensive care unit; A&E, accident and emergency; ECT, electroconvulsive therapy; URTI, upper respiratory tract infection; SOB, shortness of breath; UTI, urinary tract infection.

Fig. 1. Form used to gather data from on-call senior house officers.

calls by senior nursing staff, and ensuring that there is their increasing agitation, or assessing for section 5(2) of relevant experience for training as well as service provi- the Mental Health Act 1983. Consequently these cate- sion while on call (Postgraduate Medical Education and gories were incorporated into the form that we devel- Training Board, 2005). oped (Fig. 1). Physical calls were those that related to physical symptoms that were independent of psychiatric illness. Self-harm was considered to be psychiatric in nature. Assessment was defined as when the SHO was Method the first psychiatrist to see the patient and was involved in making a decision about admission. Admission was Three surveys of the activity of SHOs on call were defined as when the decision to admit the patient had conducted in October 2002, April 2003 and October already been made, and the first on call was involved in 2004. The area covered by the on-call service was West booking the patient. Berkshire with a population of 460 000. The period If the problem was resolved with advice, the ‘call’ surveyed was from 17.00 h to 09.00 h on weekdays and column was ticked, if the SHO had to attend the ‘att’ throughout the weekends for 2 weeks. For the first column was ticked. For each call the time the task started survey the in-patient unit was at an out-of-town site, Fair and stopped was recorded, and the ward was noted Mile Hospital, with 190 beds; for the second and third using a single-letter code. Once doctors were familiar surveys the in-patient unit was at Prospect Park Hospital with the form it took less than 10 s to complete. The with 163 beds. recording of 20 calls on the forms would generate less Work for the first on call can largely be predicted than 4 min work. At the beginning and end of each on- and categorised into: (a) assessments; (b) admissions; call session the SHO was contacted to ensure that the and (c) prescribing medication for in-patients, managing forms were completed.

330 Mason et al Psychiatry at night

Table 1. Results of three surveys of experiences of first on-call doctors

Survey original October 2002, April 2003, October 2004, papers Fair Mile Hospital Prospect Park Hospital Prospect Park Hospital

Calls, n Per weekday night 9 5.3 5.4 Per weekend 24 h 8.5 8.5 10 After midnight 23 8 10 For increasing agitation 3 2 1 For monitoring of seclusion 5 3 3 Admissions, n Total 21 23 24 After midnight 4 3 4 Assessments, n Total 25 8 6 After midnight 8 0 1 Nature of call Psychiatric enquiry about in-patient or other 59 34 42 patient cared for by trust, n Physical enquiry about in-patient or other patient 17 23 22 cared for by trust, n Prescriptions, n Over the counter 3 4 5 Night sedation 5 4 4 Short-acting benzodiazepines 7 6 8 Rest period for SHO: mean, h Total per weeknight 8 12 12 Continuous per weeknight 4 9 9 Total per 24 h at weekend 7 11 11 Continuous per 24 h at weekend 5 8 9

SHO, senior house officer.

Results was being consulted about physical problems when they were not in a position to ask the patient’s own team to The total numbers of calls to the first on-call psychiatrists assess these. during the three survey periods are shown in Table 1. The reduction in the bed number when the in-patient service changed sites made no difference to the number of calls about in-patients or the number of admissions. The Resident v. non-resident number of calls for admissions was similar in all the In each 2-week period there was in general only one surveys (mean 1.25 per weeknight, range 0-4, and 2.5 situation where the doctor was said to need to get there per 24 h at weekends, range 0-6). Admissions and as a matter of urgency - this was difficult to estimate assessments accounted for a quarter of calls but three- accurately, but was probably within around 20 min. These quarters of the time spent on tasks. situations usually involved transfer of a patient to a general hospital for treatment or investigation, which Distribution of work throughout could be done without the junior doctor being present. the on-call period The immediate attendance of the SHO for situations such as a cardiac arrest was not required in any of the periods There was marked variation between periods on call. surveyed. There was no evidence that a resident doctor Therewere2-24 calls per weekday night and 3-35 for Saturday or Sunday. There was no predictability and no increased patient safety. Both junior and senior medical suggestion of ‘busy nights’ from the data. staff agreed that the first on-call psychiatrist could Increasing agitation of in-patients and the moni- operate safely as a non-resident. Switching to a non- toring of seclusion combined with assessments made up resident on-call psychiatrist reduced the number of at least 85% of calls post-midnight in all the surveys. In all working hours, since resident doctors are considered to the surveys, 60% of calls about physical problems on be working even when resting, in accordance with the weekday evenings occurred within 1h of the start of the SiMAP ruling and the Jaeger European Court of Justice on-call period, suggesting that the on-call psychiatrist Judgments (WTD Expert Group, 2004).

331 Mason et al Psychiatry at night

Influence of an overnight crisis service solution suggested by the Department of Health (WTD Expert Group, 2004) and the Academy of Medical Royal original An overnight crisis service operating in the accident and Colleges (2004) to ensure that doctors working out of papers emergency (A&E) department of the local general hours comply with the Working Time Directive. hospital was started in February 2003. This all-night service, which is staffed by experienced nurses and social workers, provides advice or a mental health assessment Medication prescription during at the request of the A&E department, on-call general practitioners, carers and service users. The aim of the the on-call period initiative was to improve the quality and increase the Between 3 and 5 calls in each of the 2-week periods rapidity of the liaison between psychiatric services and surveyed were for over-the-counter medication. the A&E department (Royal College of Psychiatrists, Although this has been frequently complained about, it 2004). The service has had a marked impact on the on- contributed only a minor part of the workload. call workload of SHOs, reducing the number of assess- In all three surveys three-fifths of the prescriptions ments performed by on-call SHOs in 2 weeks from 25 were for short-acting benzodiazepines and two-fifths (30% of which were after midnight) to between 6 and 8. were for night sedation. Although steps have been taken The proportion of nights when there were no assess- to improve training on the use of sedative medication and ments increased from 25% to 70%. Hence it was to encourage teams to plan therapeutic strategies during possible for an SHO in training to go for a number of the day, there has been no change to the number of months without having to perform an out-of-hours times the first on call is asked to prescribe these drugs. assessment. This concern that SHOs in psychiatry are not Three factors contribute to this. First, training has not gaining experience of assessments while on call because been repeated to cover the turnover of junior doctors. they are being performed by nurse-led services has been Second, the training has not involved the night nursing raised in other trusts (White, 2005). In West Berkshire, staff who request the medication. Third, more clinical SHOs are encouraged to be present at the more challen- time is being spent in the community and teams have less ging assessments so that they gain adequate experience time to plan and implement strategies for in-patients to (Gibson & Campbell, 2000; Callaghan et al,2005)in avoid the unplanned prescription of sedatives during the assessing patients for admission, managing crises and on-call period. planning the alternatives to admission. This, however, relies on the motivation and initiative of individual SHOs. Before the introduction of the overnight crisis Seclusion and agitation service there were 23 calls after midnight in the 2-week period. More than a third of these were for assessments. Calls for assessment of patients in seclusion facilities and With the overnight crisis service in operation there were for sedation of agitated patients form a large proportion between 8 and 10 calls post-midnight, of which between of the calls after midnight (Table 1). Since we conducted 0 and 1 were for assessments. the survey, nurse prescribers have been allowed to prescribe an extended range of sedating drugs (Depart- ment of Health, 2006). Mental health nurses already play Screening of calls by a senior nurse a central role in the provision of medication and have considerable knowledge and experience in this area. In March 2003 screening of calls by a senior nurse was There is evidence that nurse prescribing for acute and introduced. This had a marked impact on the number of disturbing symptoms that require rapidly responsive calls concerning psychiatric problems of in-patients and treatment leads to greater service user satisfaction those in the community (1.2 per night on weekday nights (National Prescribing Centre et al, 2005). v. 4 per weekday night), but no difference to the number It is more challenging for clinical teams to find alter- of calls made to a doctor about physical problems. Inter- natives to seclusion so that junior doctors do not need to estingly there was no reduction in the number of calls be called throughout the night to monitor a secluded about psychiatric in-patient problems over the weekend patient. (9 calls per weekend after the introduction of senior nurse screening v. 8.5 per weekend before). Miscellaneous advice over the phone was sought Discussion from doctors in 23 calls before nurse screening and between 8 and 11 after screening. Frequently it is not Meeting the requirements of the working time directive obvious why a doctor would be better able to help with requires adjustment of working patterns and attitudes of such advice than their nursing colleagues, the police, more than just the first on-call doctors. The organisation social services and other allied professionals. Our experi- of the whole multidisciplinary team during on-call periods ence was that a senior nurse was capable of providing and the regular working day must change so that first supportive advice to ward staff on issues that are not on-call psychiatrists meet the restricted working hours of obviously medical. This has been effective in reducing the the European Working Time Directive. These changes number of calls in other mental health trusts (White, should be based on evidence that they will be useful and 2005). Using a nurse as the point of contact for referrals their effects on the on-call workload should be moni- and determining the need to contact a doctor is one tored. The use of this form together with monitoring of

332 Mason et al Psychiatry at night

hours has helped to inform the evolution of different DEPARTMENT OF HEALTH (2006) Nurse PAICE, E.,WEST, G., COOPER, R., et al Prescribers’Extended Formulary. (1997) Senior house officer training: is it services and to monitor their effect on first on-call Additional Controlled Drugs from 6 getting better? A questionnaire survey. activity. Such monitoring is essential to assess the impact January 2006. http:// BMJ, 314,719^720. original www.dh.gov.uk/assetRoot/04/12/71/ of changes in service delivery on the quantity and type of POSTGRADUATE MEDICAL EDUCATION papers 04126271.pdf learning experience while on call (Calman, 2000; AND TRAINING BOARD (2005) Generic Bulstrode & Hunt, 2005). Unfortunately this form does GIBSON, D. R. & CAMPBELL, R. M. Standards forTraining.http:// (2000) The role of co-operative www.pmetb.org.uk/media/pdf/h/s/ not measure the quality of training while on call (Calla- learning in the training of junior hospital GenericStandardsForTrainingFinal ghan et al, 2005). We would recommend the use of a doctors. MedicalTeacher, 22, 05April06___1. 297-300. locally designed form similar to the one we have ROYAL COLLEGE OF PSYCHIATRISTS employed so that other trusts can determine what HERZBERG, J. & PAICE, E. (2002) (2002) Learning Objectives For SHOs. happens during first on call at night and this expensive Psychiatric training revisited - better, London: Royal College of Psychiatrists. worse or the same? Psychiatric Bulletin, http://www.rcpsych.ac.uk/traindev/ resource is used effectively, and junior doctors can gain 26,132^134. postgrad/learnobj.pdf the necessary experience. HURLEY, P. A. & PATTERSON-BROWN, ROYAL COLLEGE OF PSYCHIATRISTS S. (1999) Senior house officer training: (2003) Basic SpecialistTraining some myths exposed. Journal of the Handbook. London: Royal College of Declaration of interest Royal College of Surgeons Edinburgh, Psychiatrists. http:// 44, 324^327. www.rcpsych.ac.uk/traindev/ postgrad/bst.pdf None. MODERNISING AGENCY (2006) Using Staff Skills Effectively - Role ROYAL COLLEGE OF PSYCHIATRISTS Redesign. http://www.wise.nhs.uk/ (2004) Psychiatric Services to A&E cmsWISE/Workforce+Themes/ Departments. (Council Report CR118). References Using___Task___Skills___Effectively/ London: Royal College of Psychiatrists. roleredesign/roleredesign.htm ACADEMY OF MEDICAL ROYAL Culture, UniversityTeachers Course. WHITE, O. (2005) Training of senior COLLEGES (2004) Implementing the Oxford:The Skills Unit. NATIONAL PRESCRIBING CENTRE, house officers. Psychiatric Bulletin, 29, WorkingTime Directive.http:// CALLAGHAN, R., GABRA, H., BROWN, NATIONAL INSTITUTE FOR MENTAL 315. www.aomrc.org.uk/pdfs/ewtd-acad- HEALTH IN & DEPARTMENT N., et al (2005) On call: a valuable WTD EXPERT GROUP (2004) A 6.pdf OF HEALTH (2005) Improving Mental training experience for senior house Compendium of Solutions to Health Services by Extending the Role BALDWIN, P. J., NEWTON, R.W., officers? Psychiatric Bulletin, 29,59^61. Implementing theWorkingTime BUCKLEY, G., et al (1997) Senior house of Nurses in Prescribing and Supplying CALMAN, K. C. (2000) Postgraduate Directive for Doctors inTraining from officers in medicine: postal survey of Medication: Good Practice Guide. specialist training and continuing August 2004. London: Department of trainingand work experience. BMJ, 314, London: Department of Health. professional development. Medical Health. 740^743. Teacher, 22,448-451. BROWN, J., DE COSSART, L. & DEPARTMENT OF HEALTH (2005) The *Jules Mason Staff Grade in Old Age Psychiatry, Prospect Park Hospital, WILTSHIRE, C. (2002) Exploring views Implementation and Impact of the Newbury CMHT, Beechcroft, Hillcroft House, Rooke’sWay, OffTurnpike Road, of basic surgical trainees (senior house Hospital at Night Pilot Projects. London: Thatcham, Berkshire, RG18 3HR, email: jules.mason berkshire.nhs.uk, officers) on a basic surgical training @ Department of Health. http:// Tina Irani Senior House Officer in Psychiatry, Oxford Deanery Rotation, scheme. MedicalTeaching, 24, www.wise.nhs.uk/sites/workforce/ Oxford, Garyfallia Fountoulaki in Psychiatry, Oxford 559^561. usingstaffskillseffectively/ Deanery Rotation, Oxford, Sylvia Warwick Clinical Audit and Research BULSTRODE,C.&HUNT,V.(2005) Hospital%20at%20Night%20 Manager, Berkshire Health Care NHS Trust, Berkshire, Jane da Roza Davis Course Manual forTraining in Practice: Document%20Library/1/Hosp%20 Consultant Psychiatrist, Prospect Park Hospital, Berkshire, Peter Sudbury Educating Consultants, Changing the At%20Night%20Final%20Report.pdf Medical Director, Berkshire Health Care NHS Trust, Berkshire

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